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Abstract

Background

Early onset and high prevalence of chronic disease among Indigenous Australians call
for action on prevention. However, there is deficiency of information on the extent
to which preventive services are delivered in Indigenous communities. This study examined
the variation in quality of preventive care for well adults attending Indigenous community
health centres in Australia.

Methods

During 2005-2009, clinical audits were conducted on a random sample (stratified by
age and sex) of records of adults with no known chronic disease in 62 Indigenous community
health centres in four Australian States/Territories (sample size 1839). Main outcome
measures: i) adherence to delivery of guideline-scheduled services within the previous
24 months, including basic measurements, laboratory investigations, oral health checks,
and brief intervention on lifestyle modification; and ii) follow-up of abnormal findings.

Results

Overall delivery of guideline-scheduled preventive services varied widely between
health centres (range 5-74%). Documentation of abnormal blood pressure reading ([greater
than or equal to]140/90 mmHg), proteinuria and abnormal blood glucose ([greater than
or equal to]5.5 mmol/L) was found to range between 0 and > 90% at the health centre
level. A similarly wide range was found between health centres for documented follow
up check/test or management plan for people documented to have an abnormal clinical
finding. Health centre level characteristics explained 13-47% of variation in documented
preventive care, and the remaining variation was explained by client level characteristics.

Conclusions

There is substantial room to improve preventive care for well adults in Indigenous
primary care settings. Understanding of health centre and client level factors affecting
variation in the care should assist clinicians, managers and policy makers to develop
strategies to improve quality of preventive care in Indigenous communities.

Background

As part of the response to high levels of chronic disease among Indigenous Australians[1], there has been increasing emphasis in recent years on delivery of preventive services
in Indigenous primary health care services. This includes development and distribution
of evidence-based, Indigenous population specific preventive care guidelines [2], introduction of Medicare reimbursed biennial health checks for Indigenous adults
aged 15 years or over [3], and the newly released National Preventative Health Strategy which specifies targets
and actions for multifaceted preventive care to "close the gap" in life expectancy
between Indigenous and other Australians [4].

Previous research provides limited information on delivery of preventive care in Indigenous
primary care settings. Studies conducted in the Northern Territory (NT) have documented
substantial deficiencies in delivery of preventive care to Indigenous adults in rural
and remote communities: on average only 40-50% of preventive services were delivered
in line with the best practice guidelines [5,6]. Studies in Indigenous communities in Queensland (QLD) [7,8] have not included data on the proportion of community members who received health
checks. A national study using Medicare data showed that 3% of Indigenous Australians
aged 55 years or over attending GPs had documented use of specific Medicare items
for health checks [9]. However, the study appeared to underestimate the uptake of preventive health checks
as many Indigenous primary care services do not use Medicare items when delivering
services to clients. Thus there is substantial potential to improve the quality of
information on the delivery of preventive services to Indigenous people for the purpose
of informing implementation of the National Preventative Health Strategy.

The Audit and Best-practice for Chronic Disease Extension (ABCDE) project is a national
quality improvement initiative which aims to improve quality of care in a range of
priority aspects of Indigenous primary health care, including chronic disease care,
preventive care, and maternal and child health care [10]. During the past five years over 60 Indigenous community health centres from four
States/Territories (NT, Far West New South Wales (NSW), Western Australia (WA) and
North QLD) have formally participated in this project. The ABCDE data provide a unique
opportunity to improve understanding of delivery of preventive care in Indigenous
primary health care settings, and, importantly, to develop and implement strategies
for improvement. This paper reports baseline data on delivery of preventive care in
Indigenous community health centres participating in ABCDE with a focus on variation
in quality of care between services and across different participating regions, and
identifies the various factors associated with these variations, both at the health
centre level and at the individual level.

Methods

Participation by health centres was from five regions where we had established project
hub coordinators (Figure 1 and Table 1). On a voluntary basis, health centre managers or staff made a request for their
centre to join the project after receiving information through invitation letters,
word of mouth or meeting presentations. Sixty six (66) health centres formally participated
in the ABCDE project. Four (4) of these health centres did not have at least part
time access to a GP and were excluded from the analysis for this paper.

Figure 1.Geographic distribution of participating Aboriginal community health centres in the
study.

Baseline audits of preventive care were completed during 2005-2009. Audits covered
both paper-based and electronic clinical records. The records of health centre clients
who met all of the following criteria were eligible for inclusion: 1) aged between
15 and 54 years; 2) resident in the community for at least 6 of the last 12 months;
3) not having a diagnosis of diabetes, hypertension, ischaemic heart disease, rheumatic
heart disease, renal disease or other major chronic illness; and 4) not pregnant or
post partum at the time of the audit. Eligibility was verified by checking an up-to-date
population list of health centre clients with assistance from health centre staff
who knew the community and health centre well. A sample of 30 records, stratified
by sex and age groups (15-24; 25-39; and 40-54 years), was selected randomly from
records of eligible clients in each health centre. Thus, each random sample comprised
5 males and 5 females in each of the age groups. In communities where there were fewer
than 5 people in a sex- and age-specific group, all eligible people in that group
were included.

The audit measured 16 selected service items (see Table 2) which the preventive health care guidelines recommend for delivery every year or
every two years for all Indigenous well adults aged 15-54 years [2,11]. A summary of detailed guideline recommendations in relation to the 16 service items
is presented in Table 3. We adopted a minimum approach to assess whether these services were delivered on
a two-yearly basis. A service was assessed as delivered if there was a clear record
of delivery of the service at least once within the previous 24 months. The overall
adherence to delivery of scheduled services for each adult was calculated by dividing
the sum of services delivered by 16 (for females) or 15 (for males - pap smear excluded),
and expressing this as a percentage. For example, if there were 6 services assessed
as delivered for a male client, the overall adherence to delivery of services for
the client was 40% (6/15), interpreted as "40% of guidelines-scheduled preventive
services were delivered to the client". Health centre-level adherence was computed
as the mean of individual adherence to delivery at each centre. For each individual
service item, a percentage (from 0 to 100%) was calculated at each health centre to
represent "% of patients who received the specific preventive service".

Table 3. Recommended schedule for the adult well person's health check for Indigenous people

Clinical records were also audited for evidence of abnormal blood pressure readings,
positive protein in urine and abnormal blood glucose readings. For any abnormality
found we checked for a record of a follow-up as outlined in Table 4. A percentage was calculated for each health centre to represent "% of adults who
had appropriate follow-up of abnormal findings".

Statistical analysis

The quality of preventive care was measured in terms of adherence to delivery of scheduled
services and follow-up of abnormal findings. Treating health centres as the unit of
analysis, we compared the quality of care (based on mean percentages) between regions
using linear regression models (Tables 2 and 4). Centre percentages and mean percentages are unweighted.

1) Adherence to delivery of services and follow up of abnormal findings were treated
as dependent variables in the random effects models respectively. We constructed a
two-level (health centre and client levels) random intercept model with no explanatory
variables (also known as an empty model) [13]. In the context of multilevel modelling, the empty model provides an estimate of
the basic partition of the variability in the data between the two levels. Based on
the model, an intra-class correlation coefficient (rho in Stata [12]) between two randomly drawn individuals in a given health centre was estimated. The
intra-class correlation coefficient can also be interpreted as the fraction of total
variability in the dependent variable that is due to health centre level characteristics.
The remaining variation is attributable to client level characteristics. The term
"characteristics" used here refers to measured and un-measured factors at the health
centre and client levels.

2) Using two-level random effects regression models, we also tested associations of
specific factors at health centre (location, health service governance, accreditation
status and population size) and individual levels (age and sex) with the quality of
preventive care.

We obtained approval from formally constituted Human Research Ethics Committees (HREC,
including Indigenous health research committees where such arrangements were in place)
in each region in which the project operated, including the NT Department of Health
& Community Services and Menzies School of Health Research HREC, the Central Australian
HREC, the Western Australian Aboriginal Health Information and Ethics Committee, the
Macquarie and Far West Area Health Services HREC, and the Townsville Health Service
District HREC.

Results

Of 62 participating health centres, 47% were managed by a local or regional Aboriginal
committee (board), with the remainder government funded/operated (Table 1). Sixty nine percent of centres did not have formal general practice accreditation
and most (60%) served populations of less than 1000 people.

Records of 1839 well adults were audited (Table 1). The mean age of these adults was 32 years and 49% were men. Around 90% or more
of records from the NT, WA and North QLD centres were for Indigenous people compared
to 43% from Far West NSW centres. Twenty eight percent of adults were documented as
smokers and 23% had documented alcohol misuse. Ninety two percent of participants
had a record of health centre attendance within the previous 24 months, with acute
care the main reason for attendance and nurses as predominant health providers.

For specific preventive services, variation in delivery was evident across different
categories of services, different regions, and different health centres (Table 2). Overall, adherence was relatively high for weight and blood pressure measurement
and blood glucose testing (50-70%), followed by height measurement, urinalysis, pap
smear and STI screening (30-40%), and waist circumference measurement and brief intervention/counselling
on lifestyle modification (20-30%). Less attention was paid to oral health checks
and brief intervention or counselling regarding emotional well being (15-18%). However,
the range between health centres for delivery of almost all of these services was
from 0- > 80%.

Analyses of preventive service delivery between Indigenous and non-Indigenous adults
in Far West NSW health centres showed no statistical difference in overall service
delivery between the two groups. However, Indigenous adults were more likely to receive
services related to BMI and waist circumference measurements, blood glucose testing
and emotional wellbeing counselling.

On average, health centre-level documentation of an abnormal blood pressure reading
(≥ 140/90 mmHg) was found in 15% of adults, proteinuria in 20%, and abnormal blood
glucose (≥ 5.5 mmol/L) in 37% (Table 4). However, the range between health centres for these measures were 0-100%, 0-92%
and 0-94% respectively. North Queensland health centres had higher rates of abnormal
blood pressure, proteinuria and abnormal blood glucose compared with other regions
(P < 0.05 for comparison with NT Top End). Of those with identified abnormal clinical
findings, overall about 20-30% had a documented follow up check/test or management
plan, but the range between services was 0-100%.

Client level characteristics accounted for a large proportion of the variation in
delivery of services and in follow up of abnormal findings: 69% for overall adherence
to delivery of scheduled services (with a range of 53-79% for specific services);
and between 62-87% for follow up of abnormal findings (Table 5).

Age and sex were both independently associated with overall delivery of services,
with higher rates of delivery in the 25-39 year age group and in women (Table 6). Health centre level factors which were independently associated with higher level
of delivery of services were location (remote community vs city), community population
size (≤ 500 vs ≥ 1000), region (Top End vs FW NSW) and governance (Indigenous committee/board
operated vs government).

For follow-up of abnormal findings, North Queensland had higher rates of follow-up
of abnormal BP (Table 7) [14]. No other health centre or individual characteristics showed significant associations
with follow-up of abnormal results.

Discussion

There is substantial room to improve the quality of preventive care to Indigenous
adults in many locations across Australia - in terms of overall delivery of services,
in delivery of a range of specific services and in follow up of abnormal findings
from routine health checks. Overall, it appears that about one third of the recommended
preventive services were delivered to clients in participating health centres. Variation
in overall delivery of guideline scheduled services between health centres is striking,
with the lowest adherence to delivery being 5% and the highest being 74%. For specific
important measures such as BP screening, overall 71% of adults have a record within
the previous two years. However the variation between centres of 23-100% reveals a
critical requirement for action in some health centres. The generally small proportion
of clients with records of or plans for follow-up of abnormal clinical findings among
these 'well' adults also highlights an important area for improvement.

Limitations of this study include: 1) Health centres were not randomly selected and
their participation in the project was on a voluntary basis and enrolment was staggered
over a period of some years. Therefore, these data are not representative for the
regions involved and differences between health centres may be partly the result of
introduction of new policies over time. A longitudinal analysis including services
with more than three years of data through participating in this project will be reported
separately. 2) We relied on clinical medical records to retrieve preventive care data,
which may underestimate actual service delivery if delivered services are not recorded
in clinical records. While failure to document services may mean that services are
delivered at higher levels than reflected in our data, the failure to document delivered
services is itself a significant barrier to continuity and coordination of care and
in preventing duplication and over servicing - especially in areas of high workforce
turnover. Failure to document delivered services is therefore in itself a deficiency
in quality of care. 3) The unweighted age and sex stratified random samples are designed
to facilitate analysis of quality of care between communities. Estimates based on
this sampling approach may differ from sampling approaches designed to provide population
estimates.

The pattern of delivery of different services (with blood pressure checks and blood
glucose testing for well adults being relatively high, followed by delivery of urinalysis,
pap smear and STI screening, provision of brief interventions/counselling related
to lifestyle change, and with lowest levels of delivery for oral health checks and
counselling on emotional well being) to some extent reflects a gradient in strength
of evidence for the preventive services specified in best practice guidelines [2,15]. Practitioners appear less likely to provide some services where the availability
of referral services (e.g. for dental and mental health care [16]) is limited. However, the low proportion of adults identified as smokers in relation
to known smoking rates in these communities is an example of an important gap in documentation
of major risk factors where there are relatively simple primary care interventions
with a reasonably well established evidence base.

The comparability of these findings with similar studies [17,18] is limited by the inclusion in these studies of the general adult population, while
our study focuses on an age and sex stratified (unweighted) random samples of well
adults. People with chronic illness are likely to have increased contact with the
health systems and more opportunities for receiving preventive services, so delivery
of preventive services to well adults might be expected to be lower than for people
with chronic illness. As indicated above, the stratified random sample used in our
study may also not be representative of the study populations in each community or
of the study populations for all communities combined. Bearing these restrictions
on comparability with other studies in mind, we note that delivery of some services
(such as BP) in our study population compares reasonably well. However, the generally
low levels of delivery of care, the well known burden of chronic disease in this population,
the importance of early detection and treatment, and the high rates of attendance
by our study population at primary care centres mean that many important opportunities
are being missed and there is clearly a need for better delivery of preventive services.

High prevalence of health problems among "healthy adults" and low follow-up of identified
problems are of significant concern. Similar to previous reports from Indigenous primary
care settings [7,8], about 20%-40% of the participating "healthy adults" in our study had abnormal blood
pressure, abnormal blood sugar levels, or proteinuria. This highlights the importance
and necessity of systematically implementing preventive care for adults in Indigenous
communities for early detection and management of preventable chronic disease. A parallel
priority in preventive care is to effectively follow up and manage the abnormal conditions
identified. Failure to follow up and implement management plans means resources and
efforts invested in regular checking and screening of well adults are wasted and cannot
be translated into improved health outcomes.

Our analysis of variation in preventive care indicates health centre level and individual
client level factors have a similar level of influence on delivery of preventive care.
The finding that accreditation of services is not clearly associated with quality
of care is consistent with other research on this topic [19,20], and indicates the need for a more active approach to quality improvement (e.g. routine
use of clinical data to monitor and improve quality of care; ongoing engagement of
health centre staff in service planning, system redesign and implementation of improvement
initiatives). The finding that delivery of preventive services is better in remote
locations and worse in health centres with large service populations is likely to
be at least partly due to greater use of a number of different providers by clients
living in non-remote settings or larger centres. The finding that delivery of preventive
services is better in community controlled services than government managed services
supports the contention that community control (through its philosophy, organisation
or funding) facilitates quality and access to care [21].

The substantial proportion of variation in preventive care attributable to client
level factors points to the importance of health centre systems to deliver care in
a way that most effectively meets the varying needs of individual clients. Regarding
client level factors, we only collected demographic information of participants (i.e.
age, sex and Indigenous status). Male participants appeared less likely to access
preventive services than females in our study. This may reflect the perceptions of
many Indigenous men who consider health centres as "women's places" [22], as health centres in remote communities are predominantly staffed by females. Gender
appropriate workforce and infrastructure may encourage Indigenous men to better use
of health services. Other client level factors, such as their health literacy [23], perceptions of physical, social and cultural accessibility of the centre, and factors
which influence a client's relationship with health centre staff [24], are important influences on the delivery or uptake of preventive care. These questions
need to be investigated in future research, as well as associations of specific health
centre system factors [6,25] with preventive care.

Beyond addressing potential health centre and client level factors, a supportive health
policy has been recognised as critical to the implementation of preventive care to
populations [26]. The introduction of a new Medicare item (item 710) in 2004 for health assessment
of Indigenous people aged 15-54 years has been welcomed as an example of innovative
policy in Indigenous health [27]. However, the impact of this measure is unclear and the longitudinal analysis of
the ABCDE data should provide some evidence in this area. Previous research indicates
that the Medicare rebates for providing preventive care may have less effect in motivating
practitioners working in remote Indigenous community health centres who are usually
in salaried positions [6]. More recent policy developments include new legislation which authorises practice
nurses and Aboriginal Health Workers to access some Medicare items (e.g. for provision
of immunisation and follow up services for Indigenous people after health assessment)
[28], and introduction of the Indigenous Practice Incentives Program (PIP) to encourage
population-based care [29]. Further refinement of health policies includes strengthening direct financial and
workforce support to health centres based on needs of defined populations [30].

Conclusions

There is great potential to improve delivery of preventive services to well adults
in Indigenous primary care settings. Particular attention should be given to improving
follow-up of abnormal clinical findings identified by preventive health assessments.
The national collaborative approach that underpins the data presented in this paper
provides a significant opportunity to advance understanding of variation in care and
to develop and examine the effect of innovative strategies to enhance the quality
of care for Indigenous Australians.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

RB played a lead role in conceptualisation of study design, development of measurement
tools, project management, and revising of the manuscript. DS played a major role
in reviewing the literature and conceptualisation, conducted data analysis, and drafted
the manuscript. CC, AB, TW and ST and HB contributed to study design and facilitated
engagement of health services. MD and LO contributed to study design and development
of measurement tools. MD, LO, RK, CK, RC, HL, JH carried out field work and conducted
data collection. All authors contributed to the interpretation of findings, read and
approved the final manuscript.

Acknowledgements

This project would not be possible without the active support, enthusiasm and commitment
of staff and management of the participating health services and the contribution
made by the wider ABCD project team. The ABCD project was supported by funding from
the Cooperative Research Centre for Aboriginal Health and the Commission for Safety
and Quality in Health Care. The work of a number of people with key roles in the project
is supported by their employing organisations, including State and Territory governments
and community controlled health organisations. DS's work is supported by a National
Health and Medical Research Council (NHMRC) Capacity Building in Population Health
Grant and NHMRC Postdoctoral Fellowship (#569919). RB's work is supported by an NHMRC
Research Fellowship.

References

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Australian Government Preventative Health Taskforce: Australia: The Healthiest Country by 2020 - National Preventative Health Strategy
- Overview. Canberra: Australian Government Preventative Health Taskforce; 2009.

Australian Government Preventative Health Taskforce: Australia: The Healthiest Country by 2020 - National Preventative Health Strategy
- the roadmap for action. Canberra: Australian Government Preventative Health Taskforce; 2009.